Anthem Blue Cross is one of the largest health insurance companies in California. It is a subsidiary of Anthem Inc., which offers coverage to one in 8 Americans across the country. As an insurance company, Anthem Blue Cross accepts premiums from patients in return for healthcare coverage.

However, what happens when you receive a denial of coverage from Anthem Blue Cross? Similar to other insurance companies, Anthem may deny a health insurance claim for many different reasons. Some denials are legitimate, while others should be contested so you can receive the coverage you deserve.

If you’ve received a denial from Anthem Blue Cross, you may be wondering what to do next. The state of California requires all health insurance companies to maintain an internal appeals process. Therefore, you have the right to an appeal (and to other options for recourse) if Anthem Blue Cross denies your claim for coverage. If you feel this denial was invalid, one of the first steps should be contacting Stop Health Insurance Denial and our thorough legal team at 310-695-524. Below we have provided core information you may be looking for on your particular denial, if you do not see what you are looking for, give us a call so we can help navigate your options.

About Anthem Blue Cross 

Anthem Blue Cross is currently the largest health insurance company in California, offering coverage to nearly 1 million people. Californians rely on the coverage options provided by Anthem Blue Cross at work, at home, and during old age.

Anthem Blue Cross prides itself in providing value and quality coverage options to residents of California. However, there cases where the company issues wrongful denials to patients. Any time you rely on your insurer to provide coverage for treatment, receiving a denial letter can be devastating.

The reality is that Anthem Blue Cross (and other insurance companies) is out to make a profit. Paying off more in claims than the company generate in premiums can lead to significant losses. This is why it’s not uncommon for patients to receive denials for out-of-network coverage, experimental treatment, or policy limitations.

Luckily, and as per California law, Anthem Blue Cross has an internal appeals process that allows you to contest a denied claim.

Types of Policies Offered

One of the reasons why Anthem Blue Cross is so popular in California is because it offers a wide variety of health insurance plans. There are plans for families, individuals, employers and employees, Medicare patients, and many more. Each plan is customized to meet the needs of patients and their coverage preferences.

The company’s health insurance plans include the following.

  • Policies for individuals and families 

Anthem Blue Cross maintains comprehensive coverage options for health, dental, vision, and time life insurance. These plans are tailored for both individuals and their families to receive care when they need it. When signing up for a plan, you can choose from many different options that include coverage limits, income levels, and the number of people to be insured under the policy.

The benefit of Anthem’s individual and family plans is that you have the freedom to customize the policy how it works best for you. You can set estimates for the monthly cost, deductible amount, and whether the plan is HSA compatible or not.

Plans start off with basic packages that include primary care visits for illness and injury. You can also add other benefits such as dental and vision coverage.

  • Policies for Employers 

Most Americans receive health insurance from their place of work. Therefore, employers form a large share of Anthem Blue Cross’s customer base.

The key to a good employer group plan is flexibility, affordable costs, and a wide variety of tools (that give employers the control they need over their plan). Anthem provides tailored plans that allow employers to select their preferred doctors, plan details, and special options such as pharmacy and dental.

  • Policies for Medicare patients

Medicare patients also have many different options available at Anthem Blue Cross. They can access Medicare Advantage plans, Supplement plans, and plans for prescription drug coverage.

Filing a Claim with Anthem Blue Cross

Filing a claim is the process of having your medical bill received, reviewed, and paid by the insurance company. In most cases, it is your healthcare provider who will submit a claim on your behalf so they can be reimbursed for services provided. This is especially true for providers who are within the insurer’s network. Anthem Blue Cross maintains an extensive network of doctors, hospitals, and other providers who administer care to insured patients and are reimbursed when a claim is made.

However, there are cases where you may need to submit a claim yourself. This often occurs if you had to pay for services out of pocket and you’re looking to be reimbursed for the expenses incurred. There are also cases where you may be seeking pre-approval for a specific procedure. Your doctor may have recommended medication, surgery, or any other treatment for a condition that you face. In response, you would then submit a claim to Anthem Blue Cross to request for coverage.

Claims may also be submitted during/after seeking treatment from an out-of-network provider. Out-of-network providers don’t have a pre-negotiated contract with Anthem Blue Cross, thus they may offer services at a higher rate than normal. However, you may have no choice but to seek out-of-network treatment if it’s the only option available.

When submitting a claim to Anthem Blue Cross, make sure you use the following steps as a guide.

  1. Use the right claims form 

Each policy offered by Anthem has a specific claim form. The purpose is to keep everything clean and organized. Make sure you use the right form to fill out your request for coverage.

  1. Obtain all necessary information from the provider 

The next step is to collect all relevant information from your healthcare provider. Include all medical documents, services and procedures received, and the contact information of your provider.

  1. Ensure that your plan covers the treatment you sort

A common reason why Anthem Blue Cross denies claims is because the original plan didn't cover the treatment. Make sure the services you received are covered by your plan (including all exceptions) at the time of application.

If there were any special circumstances involved (such as seeking out of network care for emergency services), make sure include a detailed explanation of your situation.

  1. Pay attention to time limits 

Anthem requires that all claims be filed within a specific period. In most cases, a claim should be submitted within 30 days of receiving treatment (specific timelines will vary by policy).

After you successfully submit a claim, it will be processed (by a claims processor) within the company. The claims processor will verify that you qualify for coverage and they will offset the expenses covered by your policy. If there are any remaining portions that you need to cover, you will receive a final bill from your provider.

Insurance Denials by Anthem Blue Cross

With the excellent advertising carried out by Anthem Blue Cross, you may think that it’s impossible to receive a denial for coverage. Indeed, the company presents itself as having the needs of all patients at heart. While this may be true in some cases, other patients end up in longstanding legal battles with Anthem Blue Cross over coverage denial. It’s not uncommon for patients to submit a claim before or after receiving treatment, only to end up with a denial letter.

There are many reasons why your claim for coverage with Anthem Blue Cross may be denied. Here are some common reasons why denials happen.

  1. The treatment was received out-of-network 

Anthem Blue Cross is known for denying claims for treatment that was received out of network. Because there is no pre-established relationship between an out-of-network provider and Anthem, the company may end up paying higher rates for routine procedures, urgent care, and emergencies. This is the primary reason why most health insurance companies deny claims for out-of-network coverage.

However, there are many circumstances where an out-of-network provider is your only option. Some examples include:

  1. Emergency treatment
  2. Anthem’s network of providers does not provide the procedure you need
  3. The nearest in-network provider is too far away
  4. When you have a pre-established relationship with an out-of-network doctor

It’s always a good idea to first seek treatment from Anthem Blue Cross’s expansive network of providers (if possible) before seeking out-of-network treatment. This will result in a lower likelihood of denial or conflict.

  1. The treatment is experimental 

Experimental procedures are also a common reason why claims are denied and appeals are filed. According to Anthem Blue Cross, any procedure that isn’t supported by adequate medical evidence (or isn’t carried out frequently enough by medical professionals) can be classified as being experimental.

Conflict often arises if this treatment is the only available a patient has. For example, Anthem Blue Cross used to deny lumbar artificial disc surgery (for patients with spinal complications) for many years. They categorized the procedure as being investigational in nature, despite it being commonly practiced and FDA approved since 2004. After a lawsuit was filed against the company, it eventually accepted lumbar artificial disc surgery as a medically necessary treatment for spinal complications.

Anthem Blue Cross also repeatedly denies coverage for proton therapy as a cancer treatment. This occurs despite the fact that 9 out of 10 nationally ranked cancer treatment centers provide proton therapy on a regular basis. In August 2018, a Virginia resident sued Anthem Blue Cross of Virginia for denying her claim for coverage. The company cited proton therapy as being experimental, despite how regularly the procedure is used to treat various forms of cancer.

  1. The treatment is determined as not medically necessary 

Yet another reason why Anthem denies claims is if the company classifies your treatment as “not medically necessary.” Many weight loss procedures, cosmetic surgeries, and eating disorder therapies are classified as being “medically unnecessary”.

This classification is a common cause of conflict between patients and Anthem Blue Cross. There are many situations where a patient with obesity or diabetes may benefit from a weight loss procedure (or therapy for an eating disorder). Therefore, if you receive a denial from Anthem for a treatment being classified as “not medically necessary”, don’t hesitate to file an appeal.

How to Appeal an Anthem Blue Cross Denial

If you’ve received a denial letter from Anthem, you can file an appeal to have the decision reviewed. Anthem has an in-house appeals team that will give your claim a second look and determine if you should receive coverage. Most appeals are required to be submitted within 180 calendar days of receiving your denial letter. However, individual policies may have their own variations and timelines.

The process of submitting an appeal with Anthem Blue Cross is as follows.

  1. Fill out the application form 

The appeals process starts with filling out an appeal form. The form can be obtained from Anthem Blue Cross’s website, where you can download it and include it in your appeal packet.

  1. Include supporting information 

Along with your appeal, make sure you include the following supporting information:

  1. Your name and policy number
  2. Information regarding your healthcare provider
  3. Dates when you received service
  4. The claim number you received for your initial claim
  5. Reasons for contesting the appeal
  6. Supporting medical documents

 

  1. Review by an administrative panel

Once you submit your appeal, it will be independently reviewed by a team that wasn’t involved in the initial decision-making process. Anthem maintains this independent review in an effort to provide objectivity to your appeal.

  1. A decision rendered within 30 days

Most appeals are settled within 30 calendar days of receipt of the application. If your case is an emergency, you can request to have it expedited. Expedited reviews are typically settled verbally within 72 hours, and formally within 3 days.

  1. Pursuing an external appeal 

If your appeal is denied by Anthem, you can apply to have the claim reviewed by an external body. An external review involves experts not affiliated with Anthem Blue Cross taking a look at your claim and determining if it’s valid. They will analyze your policy statement, medical documents submitted, and the initial reason for denial.

  1. Independent Medical review 

Members of Anthem Blue Cross also have the option of having their denied claim reviewed by an Independent Medical Body. This process, referred to as an Independent Medical Review (IMR), involves applying to the California Department of Managed Health Care (CDMHC) within 6 months of receiving your denied claim.

The independent body will then have your application reviewed by an Independent Review Organization (IRO). Anthem Blue Cross must follow the decision made by the IRO.

What Are Your Chances of Winning an Appeal?

As a large insurance company, taking on Anthem Blue Cross can be challenging for any patient. Pursuing a denied claim is often a lengthy and time-consuming ordeal that causes many patients to give up along the way. However, if you remain committed to the cause, you can successfully appeal a denied claim.

There are many reasons why claims are wrongfully denied. Some common treatment options may be purposefully classified as being experimental, even if they’re commonly carried out by medical practitioners. You may also be denied coverage for emergency services received from an out-of-network provider.

If you have a strong reason why your claim shouldn’t be denied, you should follow through with the appeals process and fight for the coverage you deserve.

You can also file your appeal based on Bad faith, breach of contract, and fiduciary duty. Anthem owes a fiduciary duty to all its customers to provide reasonable coverage in exchange for monthly premiums. Therefore, if you feel that the company acted in bad faith by declining your claim, you can file an appeal based on the grounds of fiduciary duty.

Help for Anthem Blue Cross Health Insurance Denials Near Me 

Being denied coverage by Anthem Blue Cross can be difficult to swallow. You may be faced with a hefty medical bill to settle, or denied coverage for a procedure that’s necessary to restore your health.

When seeking to pursue an appeal, make sure you have a lawyer by your side. Anthem Blue Cross is a large insurance company that can put up a solid defense in its favor. In response, you need a law firm that has experience in fighting against insurance giants and securing coverage for policyholders.

Stop Health Insurance Denial are the professionals you need to facilitate your appeal and represent your interests. We will take time to thoroughly review your case, establish a strong argument in your favor, and follow through with the appeals process. Has Anthem Blue Cross denied you coverage? By contacting us at 310-695-5241 today, you can schedule your free consultation with one of our experienced insurance denial lawyers.